Please complete the application form and seek the endorsement of your Rotary club.

The completed application form,together with any additional details,is to be forwarded by
23rd March 2018to:

PAG Dennis Dwyer

Post to:6 Herberts Road, Longford 7301 or email:

APPLICANT INFORMATION

Nameinfull(asitappearsonyourpassport)

FIRST (GIVEN)MIDDLELAST (FAMILY)

DateofBirth______/ ______/ ______RotaryID(ifknown):

Mailing Address

NUMBERANDSTREET

CITY/TOWNSTATEPOSTALCODE

HOMETELEPHONEMOBILE

E-MAIL

Person to notify in case of emergency

RELATIONSHIP

NAME

NUMBERANDSTREET

CITY/TOWNSTATEPOSTALCODE

HOMETELEPHONEMOBILE

E-MAIL

CREDENTIALS FOR TEAM LEADER POSITION(Attach separate page if needed)

Profession:

POSITIONCOMPANY

Rotary Club: Years in Rotary:

Club or District committee involvement:

Leadership experience (within and outside Rotary):

Community involvement:

Travel/International experience:

Additional relevant experience/knowledge that specifically qualifies applicant for team leadership:

TEAM LEADER APPLICANT’S CERTIFICATION

If appointed as Professional Development Exchange team leader, I will accept the appointment and agree to discharge the following obligations and responsibilities:

Pre-departure

  • Inform the selection committee of relationships (professional or personal) to any non-Rotarian team member applicants.
  • Be well-informed on Australia and Rotary.
  • Inspire the team with a sense of mission.
  • Build a well-informed and cohesive group that is able to present relevant presentations about Australia, and Tasmania in particular, to Rotary clubs and Rotarians in the host district.
  • Assume responsibility for facilitating all aspects of the exchange.
  • Take an active role in the team’s pre-departure orientation to ensure that it is knowledgeable about the country(ies) to be visited and thoroughly acquainted with the aims, objectives, and ideals of Rotary and the purpose of the Professional Development Exchange program to further international understanding and goodwill.
  • Confirm that vocational visits have been planned by the host district and that they conform to the team members’ expectations and professional needs.
  • Actively participate in a language and cultural training program if language differences exist between the paired districts.
  • Help team members prepare speeches that they will be asked to give at Rotary club meetings and other functions. Also help them plan a major presentation (at least 30 minutes) for the host district conference if the team is expected to attend and be part of the conference program.
  • Facilitate the team in composing a group presentation that is adjustable in length.
  • Understand that the funded provided by Rotary District 9830, with assistance of a Rotary Foundation District Grant, will not cover all expenses related to the exchange. Also accept that local Rotarians will provide for my accommodations and travel in the host district during the study tour.
  • Obtain details of travel insurance coverage provided by Rotary and agree to pay for obtain insurance that may be necessary above that cover. Participants should consult with an insurance professional to determine which coverages and limits will be adequate to cover them in the geographical location(s) to be visited.
  • Have a medical examination and submit to the District Professional Development Exchange chair a MEDICAL CERTIFICATE completed and signed by the examining physician(s) on the form to be provided.

During exchange

  • Represent the governor of Rotary District 9830 Tasmania.
  • Not be the current district governor, governor-elect, immediate past governor, or the spouse of any of the aforementioned officers when the team travels.
  • Use my communication and other skills to act as adviser and counselor when the need arises and as liaison between the host clubs/district and the team.
  • Be willing and able, physically and emotionally, to keep pace with the vigorous program of study planned for the team members.
  • Refrain from engaging in dangerous activities.
  • Refrain from engaging in any type of medical practice or activity including but not limited to routine medical procedures, surgical procedures, dental practice, contact with infectious diseases. Educational program participants who engage in this type of prohibited activity are reminded that they are solely responsible for any and all liability that may arise from their participation in this activity, including providing for adequate insurance.
  • Have proficiency (preferably fluency) in the major language(s) of the host district.
  • Remain with the team throughout the study tour, except during those periods when individual team member activities are scheduled.
  • Under no circumstances will I plan to leave the Professional Development Exchange tour before its conclusion.
  • Be available to team members to discuss any concerns and keep the team informed of my whereabouts at all times.
  • Maintain standards of behavior and deportment during travels with the exchange team that will reflect credit on Rotary, my district, and my country.
  • Have sufficient funds to meet personal and incidental expenses while abroad.
  • Not be accompanied by spouse or other relatives or dependents on the Professional Development Exchangetour under any circumstances.
  • Should I be required to return home prematurely due to travel safety concerns, and I choose to stay, I accept all responsibility for my safe return home and agree to forfeit an appropriate portion of any Rotary funding provided for the exchange.

Post-exchange

  • Within two months of my return home, submit a Professional Development Exchange Final Reportof my study tour experiences to my district Professional Development Exchange chair.
  • Ensure that all team members participate in a post-exchange debriefing and submit final reports.
  • Be willing to participate on selection committees for future teams.
  • Permit Rotary International and The Rotary Foundation to share my name and contact details with other Professional Development Exchange teams upon request.
  • Unless I indicate otherwise in writing, by submission of the photos in connection with my final report, I hereby give publication rights to Rotary International and The Rotary Foundation for promotional purposes to further the Object of Rotary, including but not limited to Rotary International and The Rotary Foundation publications, advertisements, and websites. I also authorize Rotary International and The Rotary Foundation to share photos from my final report with Rotary entities for promotional purposes to further the Object of Rotary. I do not authorize Rotary International and The Rotary Foundation, or any other entity to use these photos for any commercial purpose.

IherebyreleaseanddischargeRotaryInternationalandTheRotaryFoundationofRotaryInternationalandtheirrespectivesuccessors,officers,directors,agents,andemployeesfromanyandallclaims,damages,liabilities,orexpenseswhichIormysuccessors,dependents,beneficiaries,heirs,executors,administrators, or assigns may or hereafter have against any or all of such parties on account of or in connection with the Professional Development Exchange or my participation therein. I agree that I shall indemnify and hold harmless Rotary InternationalandTheRotaryFoundationofRotaryInternationalandtheirrespectivesuccessors,officers,directors,agents,andemployeesagainstanyandallclaims,damages,liabilities,orexpenseswhichanysuchpartymayincuronaccountoforinconnectionwithmyparticipationinthe Professional Development Exchange.Theforegoingreleaseandindemnityshallcontinuetoapplytoeachofficer,director,agent,oremployeeeventhoughsuchindividualsmayceasetoserveinsuchcapacitiesandshallinuretothebenefitofthelegalrepresentatives,successors,andassignsofsuchindividuals.IagreethatIwillabidebyallFoundationdecisionsrelatedtotravelsafety.IftheFoundationdetermines,initssolediscretion,atanypointintheProfessional Development ExchangeprocessthatmysafetyasaProfessional Development Exchangeparticipantinthehostcountryisorcouldbe at risk,the FoundationmayrequirethattheProfessional Development Exchangeitinerarybe modified,cancelled, orindefinitelypostponed. If alreadyinthehost country, myProfessional Development Exchangeteammaybeaskedtoreturnhomeimmediately.Insuchinstances,IagreetoabidebytheFoundation’sdecisionastowhat,ifany,alternativesareavailabletoProfessional Development Exchangeteamswhosetripshavebeenmodified,cancelled,orpostponedduetosafetyconcerns.

NAME OF TEAM LEADER APPLICANT

______/ ______/ ______

SIGNATUREDATE

ROTARY CLUB ENDORSEMENT

The Rotary Club of proposes
for district Professional Development Exchange team leader and forwards his/her application for consideration by the district Professional Development Exchange committee.

NAME OF CURRENT CLUB PRESIDENT

______/ ______/ ______

SIGNATUREDATE

PROFESSIONAL DEVELOPMENT EXCHANGE TEAM LEADER APPLICATIONPage | 1